By: Kathryn O’Callaghan and Jeffrey Shuren, M.D., J.D.
The world was a very different place in 1976, when the Food and Drug Administration launched its medical device program.
Since Steve Jobs and Steve Wozniak were just that year launching a computer company called Apple, doctors weren’t yet able to view X-ray images or look up drug prescribing information on their iPhones. Moreover, patients couldn’t Google treatments for heart disease, nor were they able to instantly find all open U.S. clinical trials for breast cancer. Not only was patients’ access to health care information much more limited, so was their role in making their own health care decisions.
Doctors diagnosed. Doctors made treatment decisions. Patients followed directions.
It’s different now.
Patients are more empowered today. Driven in part by a need to address emerging or neglected illnesses, such as HIV/AIDS and rare disorders, patients over the past three decades have increasingly banded together, creating organizations that advocated for their interests and generated public awareness of their diseases, their needs, and the lack of effective therapies. This activity produced legions of informed and empowered patients, who today urge us to take a more active role in our own health and urge clinicians to engage patients in shared health care decision-making. Patients are now not only partners in their health care but active consumers who make choices about their doctors, treatments, diagnostics, and health care experiences, an empowerment that is affecting the development of innovative therapies and new clinical solutions.
Today, there are no health care debates, discussions and decisions without considering the patient perspective.
At FDA’s Center for Devices and Radiological Health (CDRH), we have been systematically involving patients in our regulatory decision making process. Since 1999, CDRH has included a patient representative on each of our advisory panels of outside experts, giving us a better understanding of patient concerns about particular technologies. And in 2012, we began focusing our medical device approval decisions on incorporating the patients’ perspective.
Under this benefit-risk framework for high-risk and innovative, lower-risk medical devices, CDRH’s health care professionals, scientists, and engineers consider the patients’ perspective on both a product’s benefits and their tolerance for any risks when weighing the evidence to determine whether or not to approve a product.
In the past, CDRH experts may have determined that a device should not be approved because its probable risks outweighed its probable benefits. However today, under a patient-centric assessment of risk, if adequate evidence indicates that a subset of well-informed patients with a particular illness or condition would value the product’s benefits more than its risks, CDRH may approve the device for that particular group. However, if we were to approve such a device we may require appropriate product labeling that clearly defines the patient sub-population and their benefit-risk preference. That information would be included in the product’s “Indications for Use” section of the label to ensure that patients and health care practitioners are able to make well-informed decisions.
Better tools are needed to more reliably and scientifically characterize patient preferences about benefit and risks, so we launched our Patient Preferences Initiative, to identify and develop methods for assessing patient valuations of benefit and risk related to specific device types and specific illnesses and conditions.
The goal is to ensure we have sufficient confidence in these methods to rely on them to inform product approval decisions.
Earlier this month, a team of FDA scientists led by Telba Irony, PhD, Chief of General and Surgical Devices Branch in the Division of Biostatistics, published an article in Surgical Endoscopy with leading behavioral economists at RTI Health Solutions, a business unit of RTI International, illustrating how this paradigm can inform medical device approval decisions. The authors successfully tested a new method for capturing patient sentiment and translated it into a decision-making tool for incorporating patient preferences into clinical trial design for obesity treatments. They were able to estimate the tradeoffs in risks that obese patients are willing to accept in exchange for a certain amount of weight loss, and the minimum number of pounds they would have to lose to tolerate the risks of a weight loss device.
Shortly after the study was published, FDA approved a new weight loss device – the Maestro Rechargeable System, an important therapeutic option for obese patients. The decision to approve the device was based in part on the data from Irony’s study that showed a substantial portion of obese patients would accept the risks associated with a surgically implanted device if they lost a sufficient number of pounds. Maestro is the first FDA-approved obesity device since 2007.
Our Patient Preferences Initiative is testing other ways to reach out to patients and capture their views through public workshops, websites, and a new patient-focused advisory committee. CDRH is also participating in related research as a member of the Medical Device Innovation Consortium (MDIC), a non-profit partnership between the FDA, National Institutes of Health, Centers for Medicare & Medicaid Services, and 43 medical device companies, patient groups and other non-profit organizations. MDIC is developing a framework for incorporating patient preferences into the device development and assessment process, and compiling a catalog of methods for collecting patient preference information that can be used to develop, design, and market devices that meet the needs of patients. Simultaneously, CDRH is developing draft guidance outlining how data from patient preference assessment tools can inform device approvals and other regulatory decision making.
As patient groups, industry sponsors, and others conduct more patient preference studies, we will better understand the tradeoffs that patients with medical device-treatable diseases and conditions are willing to make. This research, along with actions taken by CDRH, MDIC and others will drive more patient-centered device development and assessment. As a result, patients will play an influential role in determining which treatments and diagnostics are available in the U.S. market.
It may have taken more than 30 years, but patients are finally having their say.
We should take care to listen.
Kathryn O’Callaghan is Associate Director for Science and Strategic Partnerships (Acting), FDA’s Center for Devices and Radiological Health
Jeffrey Shuren, M.D., J.D., is Director of FDA’s Center for Devices and Radiological Health